Patient Positioning, Chest Marking, and Robotic Port Placement for Robotic Mitral Valve Repair

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 After the induction of general anesthesia and intubation, the patient was placed in the supine position and slid to the right of the bed, so that the lateral chest was against the edge of the bed, and the right arm was allowed to hang. A shoulder roll was placed underneath the right shoulder for support. Then the right arm was padded with abdominal pads to prevent pressure injuries during the procedure. The underlying sheet was used to create a sling to support the right arm, which was tucked underneath the patient to decrease the risk of brachial plexus injuries. Additional pieces of pink foam were placed behind the right shoulder and right arm for further support. The same process of padding and tucking was repeated with the left arm, ensuring not to excessively tuck the arms, as this could affect the radial A-line tracing. 
 
Port Placement Anatomy 

Three major anatomical lines were important to this discussion: the standard sternum midline, the midclavicular line, and the anterior axillary line.  

First, a 3 cm working port was created immediately medial to the anterior axillary line in the third intercostal space (ICS). Continuing along the third ICS, an 8 mm camera port was placed immediately lateral to the midclavicular line. Next, in the fifth ICS, the right arm port was placed immediately medial to the anterior axillary line, while the left arm port was placed in the second  ICS immediately medial to the midclavicular line.  

Finally, a retraction port was placed in the fourth ICS, 1 cm medially to the mid clavicular line. Please remember to maintain enough port separation between the port sites to avoid robotic arm collisions; 8 cms or one hand width is usually sufficient. 

Using the anatomical marks defined in this video ensures consistent port placement, which is especially important in patients with challenging body habitus to optimize visualization and robotic arm ergonomics. For optimal camera port placement, find the midpoint of the sternum, and place the port in the corresponding area, halfway between the midclavicular line and the anterior axillary line. Using this approach allows for consistent placement of the camera to be focused on the superior pulmonary vein once inserted into the chest. 

References

1. Chitwood WR Jr. Robotic mitral valve surgery: overview, methodology, results, and perspective. Ann Cardiothorac Surg. 2016 Nov;5(6):544-555.
2. Chitwood WR Jr. Robotic Mitral Valve Repair: How I Teach It. Ann Thorac Surg. 2019 May;107(5):1297-1301.
3. Wong DH, Yost CC, Rosen JL, Wu M, Guy TS. Totally Endoscopic Robot-Assisted Aortic Valve Replacement and Complex Mitral Valve Repair: The Lateral Approach. Innovations. 2022;17(4):355-357.
4. Mick SL, Kohlbacher B, Gillinov AM. Robotic mitral valve repair: The steps to success. JTCVS Tech. 2023;22:49-52.
5. Amabile A, Mori M, LaLonde M, Krane M, Geirsson A. Totally endoscopic, robotic-assisted redo mitral valve re-repair. JTCVS Tech. 2023 Oct 20;22:80-81.

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